Welcome! Please tell us about yourself.

Name *

First

Last

Email *

Phone number *

Name of Primary Practice *

Business Address

City, State, Zip Code *

Business Phone Number *

Website

Credentials (Please provide the LICENSE NUMBER and STATE of practice) *

Which treatment modalities do you use most in practice? *

Acceptance and Commitment Therapy (ACT)
Adlerian
Applied Behavioral Analysis
Art Therapy
Attachment-based
Biofeedback
Christian Counseling
Coaching
Cognitive Behavioral (CBT)
Compassion Focused
Culturally Sensitive
Dance/Movement Therapy
Dialectical (DBT)
Eclectic
EMDR
Emotionally Focused
Existential
Experiential Therapy
Expressive Arts
Family / Marital
Family Systems
Feminist
Forensic Psychology
Gestalt
Gottman Method
Humanistic
Hypnotherapy
Imago
Integrative
Internal Family Systems (IFS)
Interpersonal
Intervention
Jungian
Mindfulness-based (MBCT)
Motivational Interviewing
Multicultural
Narrative
Neuro-Linguistic
Neurofeedback
Parent-Child Interaction Therapy (PCIT)
Person-Centered
Play Therapy
Positive Psychology
Prolonged Exposure Therapy
Psychoanalytic
Psychodynamic
Psychological Testing and Evaluation
Rational Emotive Behavior Therapy (REBT)
Reality Therapy
Relational
Sand Play
Solution Focused Brief (SFBT)
Somatic
Strength-Based
Structural Family Therapy
Supervision Services
Transpersonal
Trauma Focused
Other Treatment Orientation

Other Treatment Orientation

Modality (Please choose a maximum of three)

Individuals
Couples
Family
Group

Age Specialty *

Do you have special interest in treating these clients? *

Do you have a special interest in treating clients of a particular spiritual/religious persuasion? *

Do you prefer to work with client from a specific religious denomination? (Ex. Baptist) *

If so, please provide the denomination

What is the price range of the services you provide? (Ex. From $80 to $150 per session) *

Do you accept sliding scale payments? *

Do you offer free face-to-face consultation? *

Do you offer free phone consultation? *

Do you sometimes use video chat, Skype or an online therapy service? *

Are you currently accepting new clients? *

Please check all of the payment methods you accept *

Do you accept insurance? *

Please select all of the insurance providers for which you are credentialed or in-network (Check a maximum of 20) *

Other Insurance Providers

Do you have malpractice insurance? *

Please provide the Malpractice Carrier and Expiration Date of your Insurance (MM/YY) *

Please provide your NPI number

Please list the contact information you would like to make public for potential client contact. **Please note the mode of contact you indicate HERE will appear on your public profile for potential client contact** *

By checking this box, I am giving Melanin Therapy permission to make the above contact information public for use by potential clients. *

Professional Biography *

***1500 WORD MAXIMUM PLEASE***

Professional Photo *